Provider Demographics
NPI:1164417457
Name:MITKOFF, MELISSA E (NP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:MITKOFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:5 PALISADES DR
Practice Address - Street 2:STE100
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6433
Practice Address - Country:US
Practice Address - Phone:518-438-4493
Practice Address - Fax:518-438-5803
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430108-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02049558Medicaid
CC1204Medicare UPIN
NYS99435Medicare ID - Type Unspecified